March 12, 2009 - umassmed.edu · March 12, 2009 John F. Keaney, Jr., ... Select the Title Slide...
Transcript of March 12, 2009 - umassmed.edu · March 12, 2009 John F. Keaney, Jr., ... Select the Title Slide...
March 12, 2009
John F. Keaney, Jr., M.D. Professor of Medicine , UMass Medical School Chief, Cardiovascular Medicine, UMass Memorial Healthcare
Prevalence Most common cardiac arrhythmia US Prevalence about 1% Increases significantly with age
If you are older than 65, AF prevalence is 5% Over age 85, prevalence is 10%
April 10, 2013
Stroke Prevention in AF
2580 Patients > 65 Dx of hypertension and
no clinical AF Recent pacemaker or
implantable defibrillator Used devices to monitor
for AF over 3 mos Then determined
outcome over 2.5 years
April 10, 2013
Stroke Prevention in AF
Risk of Clinical Atrial Arrhythmia
Healey et al., NEJM 2012;366:2
Atrial fibrillation is a prevalent condition Increases with age, so demographics
predict more AF in your patient population AF confers increased morbidity and
mortality, with stroke being a chief cause 10 – 25% of AF is undetected, so the above
estimates are likely LOW
April 10, 2013
Stroke Prevention in AF
April 10, 2013
Stroke Prevention in AF
JACC Vol. 57, No. 11, 2011 ACC/AHA/ESC Practice Guidelines March 15, 2011:e101–98
Irreversible Cox1 inhibition
Preferentially acts upon platelets
Only need 81 mg/d
April 10, 2013
Stroke Prevention in AF
JACC Vol. 57, No. 11, 2011 ACC/AHA/ESC Practice Guidelines March 15, 2011:e101–98
Vitamin K antagonist 50 yrs of experience Sensitive to diet and
gut flora Target INR 2.0 – 3.0 in
absence of other conditions
Universally hated by patients
April 10, 2013
Stroke Prevention in AF
Inci
denc
e ra
te (p
er 1
00 p
erso
n-ye
ars)
INR Range
0
20
40
60
80
100
0 1.0–1.9 2.0–2.4 2.5–2.9 3.0–3.4 3.5–3.9 4.0–4.4 4.5–4.9 >5.0
INR = international normalized ratio.
Incidence Rate of First Ischemic or Hemorrhagic Complication
Calculating CHADS2 score for AF patients If CHADS2 ≥ 2, oral anticoagulant If CHADS2 < 2, check CHADS2-VASc
• If CHADS2VASc = 0, ASA • If CHADS2VASc = 1,oral anticoagulant preferred • If CHADS2VASc ≥ 2, oral anticoagulant
April 10, 2013
Stroke Prevention in AF
April 10, 2013
Stroke Prevention in AF
Direct thrombin inhibitor
80% Renal excretion T1/2 12 – 17 hrs No good monitoring
mechanism Orally active
April 10, 2013
Stroke Prevention in AF
18,113 randomized to dabigatran (110 or 150 mg) vs. warfarin
Non-inferiority Warfarin non-blinded Follow-up 2.0 years Endpoint stroke or
systemic embolization Healy et al. NEJM 2009
Increased risk of bleeding in patients with renal insufficiency (Cr Cl<30 ml/min)
In patients >75 years; increased risk of GI bleeding
Signal of increased MI, but likely that warfarin is protective
April 10, 2013
Stroke Prevention in AF
April 10, 2013
Stroke Prevention in AF
Direct factor Xa inhibitor
Orally active T1/2 8 - 12hrs Factor Xa inhibited
for 24h No good monitoring
mechanism No reversal agent.
April 10, 2013
Stroke Prevention in AF
14,264 randomized to rivaroxiban (20mg) vs. warfarin
Non-inferiority Blinded Event-driven Endpoint stroke or
systemic embolization
Patel et al. NEJM 2011
April 10, 2013
Stroke Prevention in AF
Direct factor Xa inhibitor
Orally active T1/2 ~ 12hrs Twice daily dosing 25% renal
elimination No good monitoring
mechanism No reversal agent.
April 10, 2013
Stroke Prevention in AF
18,201 subjects randomized to apixaban (5mg twice daily) vs. warfarin
Non-inferiority Blinded Endpoint of stroke or
systemic embolization
Granger et al. NEJM 2011;365:11
1. Calculate CHADS2, If >1, anticoagulation 2. If CHADS2=1, CHADS-VASC 3. Anticoagulation preferred if >0 4. Consider coumadin vs newer agents
April 10, 2013
Stroke Prevention in AF
Coumadin has a long track record. Compared to coumadin: Dabigatran prevents embolism with equal
bleeding, possible increase in MI Rivaroxiban has similar rates of embolism, but
less bleeding Apixaban has similar rates of embolism, less
bleeding, less death
April 10, 2013
Stroke Prevention in AF